***Must have a medical background to be able to complete this assignment without it sounding ridiculous. I have uploaded an outline. 

For this assessment the patient will be a 63 year old female with a cystocele, and chief complaint urinary incontinence. The rest of the info can be made up such as medical history meds labs just make it believable to the pt age and diagnosis. 

Comprehensive Patient Assessment

When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.

By Day 7 of Week 9

This Assignment is due. It is highly recommended that you begin planning and working on this Assignment as soon as it is viable.

To prepare

· Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.

· Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.

To complete

Write an 8- to 10-page comprehensive paper that addresses the following:

· Age, race and ethnicity, and partner status of the patient

· Current health status, including chief concern or complaint of the patient

· Contraception method (if any)

· Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)

· Review of systems

· Physical exam

· Labs, tests, and other diagnostics

· Differential diagnoses

· Management plan, including diagnosis, treatment, patient education, and follow-up care

© 2013 Laureate Education, Inc. 1

Comprehensive Write-up Guide

Week 2 Assignment: Comprehensive Patient Assessment

When completing practicum requirements in clinical settings, you and your Preceptor
might complete several patient assessments in the course of a day or even just a few
hours. This schedule does not always allow for a thorough discussion or reflection on
every patient you have seen. As a future advanced practice nurse, it is important that
you take the time to reflect on a comprehensive patient assessment that includes
everything from patient medical history to evaluations and follow-up care. For this
Assignment, you begin to plan and write a comprehensive assessment paper that
focuses on one female patient from your current practicum setting.

To complete:

Write an 8- to 10-page comprehensive paper that addresses the following:

1. General patient information
a. Age
b. Race/ethnicity
c. Partner status

2. Current health status

a. Chief concern/complaint and history of present illness (include a complete
symptom analysis of chief complaint(s) utilizing OLDCART for a sick/problem
focused visit)

b. Last menstrual period or year of menopause
c. DES exposure (if born between 1948 and 1971)
d. Sexual activity status
e. Barrier prevention
f. Sexual preference
g. Satisfaction with sexual relations

3. Contraception method (if any)

4. Patient history

a. Past medical history
• Major medical events (including pediatric events)
• Psychological and mental health
• Surgeries and/or hospitalizations if pertinent
• Medications, including prescriptions, over-the-counter medications, home

and herbal remedies, calcium, and vitamin supplements
• Allergies, including drug, food, and environment

© 2013 Laureate Education, Inc. 2

• Health maintenance/screenings, including results of patient’s last Pap and
mammogram as appropriate, as well as previous vaccinations (HPV,
MMR, hepatitis B, last dT, and pneumovax/influenza as appropriate)

b. Family medical history

c. Gynecologic history

• Nullipara vs. multipara
• History of sexually transmitted infections and sexually transmitted

diseases
• Menarche and menstrual patterns
• Menopause or peri-menopausal symptoms (if applicable)

d. Obstetric history

• Gravida and parity status (TPAL)
• Pregnancy history, including history of preterm or low birth weight, other

pregnancy complications, history of sexually transmitted diseases, and
any pertinent negatives

e. Personal social history (as appropriate to the current problem)

• Cultural background
• Education and economic condition
• Abuse history including assault and forced sex (past and current)
• Occupational health patterns
• Environment
• Current h

SOAP NOTE Week 3

Patient Initials: _D.S.____ Age: __36_____ Gender: Female_

SUBJECTIVE DATA:

Chief Complaint (CC): “I am here for my yearly exam and a refill on my birth control pills.”

History of Present Illness (HPI): D.S. is a Caucasian female, 36 years old. She appears to be in good health, with no pertinent medical history. She had her first pap when she became sexually active at age 22 and has admitted to having a total of 5 sexual partners. She states she used condoms with all her previous sexual partners. She is currently in a monogamous relationship and states that they do not use condoms every time. Her last pap was in August of 2016 and there were no abnormal findings.

Medications:

1. Ortho Tri-Cyclen 1 pill daily

2. Women’s multivitamin 1 pill daily

Allergies:

NKDA. No known food allergies. Environmental allergies- (Seasonal allergies)

Past Medical History (PMH):

No pertinent past medical history

Past Surgical History (P/SH):

1. Tonsillectomy- 1989

Sexual/Reproductive History:

Heterosexual; nulligravida

Personal/Social History:

D.S is an un-married female, lives alone, and is in a monogamous relationship with her boyfriend of 6 years. She has no children nor does she want any children. She denies tobacco, alcohol, or drug dependence. She is employed full time as a third-grade teacher. She was adopted as an infant and does not know her family history. She has considered genetic testing but is unsure if she will have it done or not.

Immunization History:

Up to date on all childhood immunizations and booster. She was offered the HPV vaccine at age 22 when she had her first pap smear, but refused. She refused the influenza and pneumonia vaccine as well.

Significant Family History:

Unknown

Review of Systems:

General: NAD noted A/Ox 3. She appears to be clean and well groomed.

HEENT:

Head: Normocephalic no trauma noted. Denies headaches

Ears: Denies hearing loss, denies ear pain, tinnitus, or vertigo

Eyes: Denies the use of contacts or glasses. Denies pain in eyes, or any recent change in vision.

Nose: Denies nasal congestion or drainage. Denies any changes in smell or epistaxis. States she has occasional seasonal allergies which causes occasional sneezing.

Throat: Denies hoarseness or any changes in taste. Denies difficulty swallowing

Respiratory: Denies shortness of breath or cough. Denies wheezing. She is exposed to second hand smoke from her boyfriend. She states she had a negative TB test completed last winter and has never